Delivery of psychological therapies and interventions: national specification

The Specification for Psychological Therapies and Interventions

In this part of the document, you can find the specific outcomes of the specification we have drafted for delivery of psychological therapies and interventions. The final document will also contain background information to introduce the outcomes. You can find the background information contained in the overview of the consultation content directly attached to this document. Questions about the specification overall can be found in the next section.

We know that currently not everyone has the same experiences or outcomes when they access services that provide psychological therapies or interventions. We want the specification to help make sure that services meet your needs whoever you are and whatever your background.

However, we know that we need to do more to listen to and learn from people and organisations as we work to improve the specification.

Everyone accessing psychological care deserves to receive a high-quality level of care, and the right support that they need, all delivered by appropriately trained professionals.

To do this:

1.1 When receiving care, a psychological formulation will be agreed with me in an outcome focused and transparent way, linked to jointly agreed goals and decision-making (See Glossary for description and an example of a formulation).

1.2 When receiving care, I will be able to provide regular feedback about the psychological care offered. With my agreement, my carers will also be able to offer feedback.

1.3 Psychological care that is offered to me will be appropriate to my needs and individual circumstances.

1.4 I will be seen when it is my turn, and this will be in a timely way. Where necessary, services will prioritise the referrals for those at risk with urgent care needs, and detail the criteria used to prioritise.

1.5 Regardless of where I live, and where possible, psychological care systems will minimise unnecessary delays and limit unequal waits across Scotland.

1.6 Psychological care will guide, support, and enable me to make informed choices about how to access the right services at the right time, based on my needs, the evidence base, and expert advice offered.

1.7 Leadership should be of a high quality and clear so that I, and others, know that the people helping us are providing safe, efficient and effective care. There will be a system wide Psychological Services Leadership Team with appropriate business management support to ensure equitable access to care is available.

1.8 The care and support I receive will be centred on my personal circumstances, taking into account cultural and social needs, and regardless of my background. There will be a commitment to reduce inequalities and improve access to psychological care for all.

1.9 Nationally agreed methods of measuring my progress during treatment will be used so I can see how the psychological care offered to me is helping me in a meaningful way. This helps services know they are offering quality care too.

1.10 Methods and systems required to record waiting times are fit for purpose and nationally adopted by all relevant health and social care services and teams. This should provide meaningful information about quality as well as quantity of care provided to others and to me by staff. (See Public Health Scotland Guidance for more details).

1.11 Services and systems will work to reduce barriers to accessing psychological care and reduce waiting times so there is timely and appropriate access to the psychological care workforce. This will include consideration of inequalities related to cultural, ethnic, and other protected characteristics.

1.12 Access to peer support can be vital to recovery, and where possible, I will be supported to connect with others with lived experience to aid recovery, if I choose to do so.

1.13 When I receive psychological care from an appropriately trained professional, I will be offered the choice to:

• Actively engage in the offers of care.
• Book into appropriate appointments offered to me.
• Discuss how I will be seen based on clinical advice and options available to me (e.g., digital, group work, or in person).
• Discuss which members of my family or care network can come with me.

To make sure people are fully involved in their care and care planning; and collaboration between professionals is crucial.

To do this:

2.1 Staff, communities and services must work with my family / carers and me to find out what I want and how professionals can help me.

2.2 The psychological care offered to me should be tailored to my needs and individual circumstances to help me live the life I choose.

2.3 All staff seeing me should use terms and language to describe what I need in a way that I can understand.

2.4 A process of shared decision-making will take place with me when receiving psychological care from a professional, to help set goals, which will be regularly reviewed.

2.5 Where possible, staff seeing me have access to wider clinical expertise from other registered professionals through supervision and joint working so their views can help inform my care.

2.6 If I receive a psychological assessment or treatment, a psychological formulation will be developed and shared with me and the best evidence base will be considered.

If I express a wish to seek psychological care from a professional, I will be offered:

• The choice to book into an appointment with an appropriately trained and supervised staff member, ideally within a maximum of 12 weeks, to discuss my needs.
• A range of available appointment times to choose from. Where appropriate, I will have the choice about where I am seen and in what location (e.g., from home via Near Me or in a building) as recommended by the person I am seeing.
• The opportunity to fully discuss my needs, so the person seeing me can advise me on what might help me, based on evidence, and what will help me get to the right intervention, at the right time. Interventions could include groups, a specialist assessment, an individual therapy, or a digital therapy. The type of treatment offered to me may, or may not, start at this first contact.
• The choice to be copied into any letters about me, where appropriate, if I wish to consent to this.
• Self-help and written materials, including treatment plans, if they are required and advised by the person seeing me.
• The first contact with an individual and team will feel helpful and meaningful to me. All advice and treatment offered will be based on the expertise and judgement of the person or service helping me.
• After this first contact, I can choose to engage in further appointments or other offers of support, if required and recommended to me. (This may include meaningful offers from other services such as third sector agencies, if appropriate).

Further contact:

• Any subsequent appointment/s will be offered according to my needs and advice of the person who saw me.
• I will have started treatment no longer than 18 weeks from referral. Therapy can be offered digitally, in person, in a group or virtual appointments.
• Once treatment has started, I will have no other unnecessary waits, appointments will be on a regular basis, and the frequency of these appointments will be matched to my formulation, assessment and treatment plan.
• I will have choice about who in the family and care network are involved in my appointments and treatment.

2.7 If for any reason, I have not started treatment within the national waiting times standard of 18 weeks (as per Public Health Scotland Guidance), the services will regularly keep in touch with me (e.g., phone calls, letters). This is not an offer of an assessment or treatment appointment but is there to offer me:

• Choice to update the service.
• Choice to update the service about any change in my circumstances.
• Choice about whether I still wish to be seen.
• Choice to discuss other avenues of support if this is available to me.
• Choice to get any information to help me while I wait.

2.8 It is appreciated that if I have complex, or urgent care needs, or I am seen in a ward setting, (e.g., those detained under the Mental Health Act, individuals presenting to 'out of hours' care, people in prison, those with acute physical health needs), there may be a different pathway to access psychological care. However, choice about care and joint planning at all stages will be offered, where clinically appropriate, and if treatment is required, it will have started within 18 weeks of the referral.

All psychological care must be right for those receiving care to make sure the best results are achieved for others and me.

To do this:

3.1 The Psychological Therapies Matrix will be used to guide delivery of the right psychological care offered to me. The Matrix is the evidence-based guide for the delivery of psychological therapies. Psychological care may also include wider choices based on the professional guidance and evidence base of the registered professional helping me (e.g., occupational interventions).

3.2 When receiving care as part of a wider health and social care system, offers of psychological care should be considered and offered to me as appropriate. I may be offered short interventions, guided self-help, or more directed support. This should be based on my individual needs and not just a diagnosis.

3.3 Psychological care will be delivered within an integrated care system, with a shared record where possible, so I do not have to keep retelling my story unnecessarily and I get the help I need.

3.4 The number of appointments and support I receive will be determined by the professionals I see, the available evidence, the service guidance, and will take account of my views and protected characteristics (e.g., intellectual disabilities). I can also discuss my needs again with a professional if I feel my psychological health deteriorates.

3.5 There may be a few sessions offered if I have (e.g., anxiety) but many more appointments would be offered if I have more complex needs (e.g., severe trauma). The appointments offered would be shared with me as part of my treatment plan as a guide, so I know what to expect.

3.6 If I do not attend an appointment, my case should not be closed due to non- attendance without contacting me, or the person that referred me. This is to make sure I am not at risk and have the care I need.

When Psychological Care is delivered, I will be an equal partner in my care. Values, rights-based, and person-centred approaches will be embedded in all practice.

To do this:

4.1 Any written information, including about confidentially, will be provided in an easy read format, use plain language and be in a format I can understand. Information should be available in formats, which are culturally sensitive, and trauma-informed.

4.2 I will be enabled to access care and support from other agencies beyond formal services, if I would find this helpful. This will include consideration of third sector or member led organisations, which support people from different social, economic, cultural and ethnic backgrounds.

4.3 Services and teams that provide care to me will reduce the risk of harms to me or others and support my overall wellbeing.

4.4 There will be a clear responsibility framework and complaints process for services and systems so I know how my concerns will be addressed.

4.5 There will be ongoing, quality improvement at the heart of offers of care. Listening to the combined voices of those accessing, and those delivering psychological therapies and interventions, will make sure that services continue to develop and improve care for all.

4.6 Empathy, kindness, and respect will be used as frameworks for all practice and I should expect this. I am expected to show kindness and respect to staff and those supporting me.

Transitions for those accessing direct psychological care across a variety of delivery partners can often be challenging. Therefore, a smooth transfer of care should be effectively planned, communicated, and implemented. (Transitions from Children's Services to Adult's Services are specified in the National Transition Principles and the CAMHS and ND National Specifications).

To do this:

5.1 There will be recognition of the importance of a good therapeutic relationship between me and the psychologically trained professional helping me; and consistency of relationship once in therapy will be the same wherever possible.

5.2 There will be effective communication between professionals, if there is any transition of my psychological care. To support continuity of care, a clear plan that has been agreed with me will be in place. Any risks will be clearly identified and documented; and the flexibility of transfer time and handover of care will be considered.

5.3 Services and teams that provide psychological care will use referral systems that are simple, consistent and efficient. Self-referral options can be offered, where appropriate, for those needing less complex types of support.

5.4 Clinical and data systems used by services will be used in a way that confidentially supports my care and does not hinder the quality of care provided.

5.5 Through implementation of the Scottish Government's Transition Care Planning Guidance, services will work with me and my family / carers to plan for transitions.

Services delivering the Psychological Therapies and Interventions Specification will continue to work in partnership with people, their families, and carers to shape aspects of service design, delivery and review.

To do this:

6.1 It is recognised that my existing support network – carers, family, or friends – are key in helping me with my support needs and the delivery of my care, should I consent to them being involved.

6.2 I will be informed that I can have someone with me, if I choose to do so, when seeking psychological support. All interventions and services will take into consideration my preferences and consent about involving my carers, family, or friends in my care.

6.3 If wanted, carers should be signposted to support and resources that are available, as they often need support too.

6.4 Peer support and / or informal support will be considered and offered as part of future service planning, where appropriate, to my family members and / or carers.

6.5 Communication between professionals and those with lived experience will be inclusive of carers and family members, where and when appropriate.

The variety in the workforce practice types, professional mix, activity of staff, and outcomes are important when delivering high-quality care. The Services Guide will provide guidance for health and social care staff on how to support service delivery and staff wellbeing to make sure workloads are shared, fair and clear where specialist and enhanced practice types of care are offered.

To do this:

7.1 There will be an adequately funded and staffed psychological workforce, taking into account specific clinical services, population need, and local circumstance so that I receive the level of care I need.

7.2 There will be enough resources available for professional, clinical and managerial supervision so that the staff and services helping me are safe and led well.

7.3 The roles and qualifications of all staff delivering direct psychological care will be clearly described in an accessible format to me and will be available for me.

7.4 Services and managers that lead services will plan how staff might be best placed and funded to ensure responsive and equitable care.

7.5 Investment in the workforce will be provided so that staff are trained to deliver interventions that help me to improve my health. All staff providing psychological care will have access to relevant learning materials, and will keep their training updated as part of routine continuous personal development.

7.6 Services will consider how psychologists can best support those with more complex need, and help train and supervise the wider workforce, including those focussing on early intervention and prevention.

7.7 There will be a Psychological Care Governance Group in my local area that will be led by the Professional Lead for Psychology, or their delegated senior clinician. All staff in Health and Social Care, who deliver psychological therapies and interventions, will be represented so that care offered to me by anyone is safe and based on evidence.

7.8 All Boards across Scotland will have leadership from a Director of Psychology. The Director of Psychology will work with leaders in health and social care systems to provide leadership and governance for all of my care to make sure that I get the equitable high quality care that I need.

7.9 Central to all leadership and planning, will be people with lived experience. My views will be sought and analysed through regular service review and research to help improve the care offered. I will be positively enabled to provide clear, regular, and meaningful feedback as standard practice.

Staff wellbeing and retention will be a key priority in psychological service delivery. To achieve this the following will be considered:

7.10 There are flexible, healthy, and safe work environments, and where clinically appropriate, options for hybrid working for staff are offered, which is balanced with my clinical needs (e.g., home and work environments). Modes of delivery of care are available to make sure there is choice for me, and that staff are available (in-person, online, groups).

7.11 The appointment duration is considered to meet my need (e.g., longer appointments for neuropsychological testing).

7.12 Time is protected for staff for joint working with other professionals, if I need help from more than one person.

7.13 The clinical staff that see me will have the right skills to help me. Clinical work should be matched to their skill set under the supervision of a trained staff member.

7.14 A supportive culture where staff can support decision-making and service improvement. Staff wellbeing will be central to offering good care to me. Staff will feel valued, and fair work principles will be applied.

7.15 Staff retention will be monitored, and any learning implemented to improve care offered to me and others.

7.16 Staff seeing me will work within their agreed objectives to support their wellbeing and job satisfaction. Time will be protected for staff to allow them to teach and continually develop the workforce.

Glossary

Advocacy makes sure that people know and better understand their rights, their situation, and systems. Independent advocates help people to speak up for themselves and speak for those who need it. An independent advocate is someone who helps build confidence and empowers people to assert themselves and express their needs, wishes and desires. Collective advocacy happens when groups of people with a shared agenda, identity or experience come together to influence legislation, policy, or services.

A carer is someone of any age who looks after or supports a family member, partner, friend, or neighbour in need of help because they are ill, frail, have a disability or are vulnerable in some way. A carer does not have to live with the person being cared for and can be unpaid.

Enhanced Practice describes therapies or interventions delivered by staff with additional skills developed through short training courses in psychological interventions and a role to provide them within protected time in their post or role. This workforce will provide psychological assessment and treatments that have proven effectiveness as indicated in the Scottish Psychological Therapies Matrix. Enhanced Practice staff also offer supervision and training to others. For example, cognitive rehabilitation for someone with dementia delivered by a nurse in a social care setting.

Evidence-based therapy is about combining the professional's skills and judgements with the available research to provide a tailored treatment plan. The effectiveness of treatment is based on scientific evidence with the goal of providing people with treatments that have solid research support for their effectiveness.

Formulation is a joint effort between the person accessing care and the professional delivering care to summarise the person's difficulties, to explain why they may be happening and to make sense of them. It may include past difficulties and experiences if these are relevant to the present. It acknowledges the person's strengths and resources. It also helps the professional to decide how to support the person to feel better and recover by thinking about how the whole system of support can help the person feel better.

Human rights are based on the principle of respect for the individual and they are the rights and freedoms that belong to every person, at every age. They are set out in international human rights treaties and are enshrined in UK law by the Human Rights Act 1998.

Informed Practice is psychological care delivered by all staff across the health, social care and third sector workforce who are involved in providing care to the public. This workforce will have knowledge and skills in recognising psychological issues. For example, a support worker identifying distress through a trauma-informed conversation with an in-patient who has cancer and informing the ward nurse.

Psychological assessment is the specific tools that are used by appropriately trained staff to assess someone's mental, cognitive, and psychological health (e.g., a cognitive assessment of someone with a learning disability using formal assessment tools).

Psychological interventions is the term used for the application of psychological techniques that help people to improve their health by helping them understand their strengths and difficulties, make changes to their thinking, behaviour, and relationships to reduce distress, treat mental health difficulties, and improve wellbeing (e.g., a neuropsychological assessment following brain injury which helps guide a treatment plan).

Psychological treatment is the evidence-based therapies and techniques used to help people with their psychological health and wellbeing.

Quality Improvement is about giving the people closest to issues affecting care and quality, the time, permission, skills, and resources they need to solve them. It involves a systematic and coordinated approach to solving a problem using specific methods and tools with the aim of bringing about a measurable improvement.

Skilled Practice is care delivered by staff with additional skills in using psychological approaches and who would generally provide them as part of their routine care. This workforce will have skills to deliver psychologically based education courses and have skills in developing good communication and listening skills. For example, a nurse providing support and education about anxiety and sleep in conversations with adults seen in a general practice.

Specialist Practice is the assessments, treatments and interventions delivered by staff with specific specialist recognised training in psychological theories and therapies as a core remit of their role. This workforce will have formal training in all levels of the Roth and Pilling Competency Framework (2015) with expertise in at least one psychological therapy. ​Specialist Practice staff also offer supervision and training to others. For example, delivery of trauma focussed Cognitive Behavioural Therapy for people who have a diagnosis of Post-Traumatic Stress Disorder and depression. Professionals trained in enhanced and specialist practice also contribute to wider public sector services through education, training, supervision, consultation, research, evaluation, and organisational support.

Trauma-informed practice is a model that is grounded in and directed by a complete understanding of how trauma exposure affects people's neurological, biological, psychological, and social development. It involves understanding the prevalence and impacts of trauma, recognising when someone may be affected, and responding in ways that does no harm and supports recovery and resilience. Five key principles underlie trauma-informed practice these are: safety, trust, choice, collaboration, and empowerment. Further information and training support for trauma-informed practice is available via the National Trauma Training Programme website: https://transformingpsychologicaltrauma.scot/

Annex A - Principles and the wider specification landscape

The Health and Social Care Standards, published in 2017, set out what people should expect when using health, social care or social work services in Scotland. This specification is not specific to mental health services. They do however contain key principles, which aim to ensure every person is treated with respect and dignity, and their human rights are upheld in line with the Equalities Act 2010.

The specification that is outlined in this document is one of a suite, which will cover mental health and wellbeing services more comprehensively. We have already developed service specifications for CAMHS and the Neurodevelopmental services for Children and Young People and are National Standards for Adult Secondary Mental Health. Our ambition is that all of these documents will be linked by a set of shared principles, which are based on the Health and Social Care Standards.

These shared principles were developed through extensive engagement, which was undertaken during the development of the CAMHS and Neurodevelopmental Service Specifications.

Mental Health Principles

1. High-quality care and support that is right for me

2. I am fully involved in the decisions about my care

3. High-quality interventions and treatment that are right for me

4. My rights are acknowledged, respected and delivered

5. I am fully involved in planning and agreeing my transitions

6. We fully involve adults and their families and carers

7. I have confidence in the staff who support me

These principles inform all of the outcomes in the specification and we would expect these principles to be applied to each of the thematic areas.

Realistic Medicine

The specification is in line with the vision for NHS Scotland that by 2025 anyone providing health and social care will take a realistic medicine approach. This approach puts people at the centre of decisions made about their care and how it is delivered.

Realistic Medicine means that people should be provided with the highest quality supports that are right for them and evidenced based interventions on discussion with them and only when they require these.

The six principles of realistic medicine are:

• shared decision making
• building a personalised approach to care
• managing risk
• reducing harm and waste
• tackling unwarranted variation
• innovating and improving

Time, Space, Compassion

The Time, Space, Compassion approach aims to ensure that those who reach the point of suicidal crisis are able to access support at a Time they need it, in an accessible and available Space, and are shown Compassion by those who are providing the support. We would expect the specification to be delivered in line with this approach.

Trauma-Informed Practice

We would expect the specification to be delivered as part of our ambition for workforces and services across Scotland to operate in a trauma-informed and trauma-responsive way. Trauma-informed services assume that people have had traumatic experiences, and as a result may find it difficult to feel safe within services and to develop trusting relationships with service providers. Consequently, services are structured, organised and delivered in ways that promote safety and trust and aim to prevent retraumatisation. This helps to ensure that our services are delivered in ways that reduce barriers and prevent further harm or retraumatisation for people who have experienced psychological trauma or adversity at any stage in their lives.

Professional Standards

We would expect that all professionals delivering psychological therapies and interventions follow all recommended service and professional and regulatory standards set out, produced and monitored by individual professional bodies and other special groups (such as The Health and Care Professionals Council).

Annex B - Process

Throughout the specification development process, we have used the PANEL Principles to ensure we took a Human Rights Based Approach.

Discussions with stakeholders emphasised the importance of a partnership approach to the specification development with the voices of those with lived experience of using services being central. A partnership approach enabled a broader range of expertise and buy in than one organisation alone.

To facilitate this partnership approach, we established the Mental Health and Wellbeing Standards Working Group in December 2021.

The primary purpose of the Mental Health and Wellbeing Standards Working Group was to ensure the development and delivery of National Standards Adult Secondary Mental Health is carried out on time and to a high standard. To ensure consistency and to save duplication of resource, the group was also an advisory group on the development of the National Specification for Psychological Therapies and Interventions.

The group brought together representatives of people with lived and living experience of using services and their carers (a carer is anyone who cares, unpaid, for a friend or family member who due to illness, disability, a mental health problem or an addiction cannot cope without their support), the mental health, psychology and social care workforce and organisations who commission mental health services.

The chair of the group – Gordon Johnston – was selected by Ministerial appointment. Gordon has lived experience of using mental health services and is the chair of Vox Scotland's board.

The working group reported to the Mental Health Quality and Safety Board at key milestones during the development of the standards. The board is chaired by the Minister for Mental Wellbeing and Social Care.

The Health and Social Care Alliance Scotland and Vox Scotland were commissioned to engage with people with lived experience of accessing or supporting those accessing psychological therapies and interventions. They engaged with people through virtual focus groups.

NHS Education for Scotland was commissioned to undertake engagement across all NHS Boards and Health and Social Care Partnership areas, and captured detailed feedback from those who attended one of the 45 engagement workshops.

In addition to the face-to-face workshops, an online survey was carried out across the workforce with 278 responses submitted from a wide range of roles.

The evidence from the engagement work and the evidence review were brought together at a Consensus Conference. The conference took place virtually and delegates included people with lived experience of using services and those who work in and lead psychology services. Delegates discussed the findings of the reports and reached consensus on their priorities for what needed to be included in the specification.

Annex C - Feedback and complaints

A key priority in the specification is that you can give feedback on your experiences of engaging with mental health and psychological services and are supported to act if you are not satisfied with your experience. This section contains information on your rights and the actions you can currently take.

The Patient Rights (Scotland) Act 2011 and supporting legislation, provides a specific right for people to make complaints, raise concerns, make comments and give feedback. The Act also places a duty on NHS Boards to thoroughly investigate and respond to any concerns raised, to take improvement actions where appropriate and to share learning from the views they receive. If you have concerns about your care or support, this should be addressed at a local level through the NHS complaints procedure. When that is not possible, the Scottish Public Services Ombudsman (SPSO) is the second and final stage in the complaints process.

The SPSO is independent from the provider of healthcare and Ministers and investigates complaints about most organisations providing public services in Scotland. Their role is to give an independent and impartial decision on complaints. Once the SPSO have completed an investigation and made a decision, they will write to the person who brought the complaint, as well as the organisation involved, and give details of that decision. This will include details of any recommendations the SPSO have made to put things right, and the deadlines by which the organisation must carry out these recommendations. There is a rigorous review process in place to ensure that recommendations have been implemented by that time.

Advocacy

NHS Boards also have a duty to provide information on the advice and support services available for people who wish to make a complaint including providing contact details of the Patient Advice and Support Service (PASS).

The PASS service is free, confidential and independent and is delivered by the Citizens Advice Bureau (CAB). The service can be accessed by visiting www.patientadvicescotland.org.uk or by telephoning: 0800 917 2127. You can also go to your Local Citizens Advice Bureau.

This service has been set up to assist people who use services and their families in raising concerns and to help them understand their rights and responsibilities when using the health services.

Care Opinion Lines

You may also wish to consider sharing your experience of the NHS via Care Opinion. This is an independent website where patients, their carers or family members can tell other people about their experiences of the NHS. NHS Boards are alerted to stories posted about services in their area and are encouraged by the Scottish Government to respond. You can share your Care Opinion story online at (http://www.careopinion.org.uk) or by telephoning 0800 122 3135.

NHS Inform

In addition, you can find further information on patient's rights and the complaints and feedback process on the NHS Inform website.